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Introduction: Retroperitoneal sarcoma (RPS) surgery poses unique challenges. This retrospective study aimed to analyze the learning curve (LC) in RPS surgery, assessing the relationship between surgical experience and outcomes., Materials and Methods: Cumulative sum (CUSUM) analysis was used to analyze 62 RPS surgeries performed by a single surgeon between 2016 and 2022 at our center., Results: The number of cases where the surgeon acted as first operator increased from 3 in 2016 to 13 in 2022. The surgeon operated with his mentor in 66.7 % of cases in 2016, whereas in 7.7 % of cases in 2022. LC consisted of 3 phases. Phase 1 (16 cases), with a negative slope, represented shorter operative time (OT) and fewer number of resected organs (RO). Phase 2 (30 cases) was the plateau phase. Phase 3 (16 cases), with a positive slope, indicated longer OT and more RO. Statistically significant differences were observed in terms of size (p = 0.003), presentation (p = 0.048), number of resected organs (p = 0.046), pattern of resection (p = 0.033), OT (p = 0.006), and length of stay (p = 0.026) between the three phases., Conclusion: This study focused on the critical role of LC in RPS surgery, emphasizing its influence on outcomes. We identified three phases, highlighting the surgeon's evolution. This offers a framework for educating sarcoma surgeons and ensuring exposure to increasing surgical complexity. In discussions on sarcoma referral centers and the correlation between case volume and outcomes, this study underlines the importance of evaluating LC to distinguish surgeons qualified to manage sarcoma cases within a referral center., Competing Interests: Declaration of competing interest None, (Copyright © 2024. Published by Elsevier Ltd.)

Background: Gastrectomy with extended lymphadenectomy is considered the gold standard treatment for advanced gastric cancer, with no age- or comorbidity-related limitations. We evaluated the safety and efficacy of curative gastrectomy with extended nodal dissection, verifying survival in elderly and highly co-morbid patients., Methods: In a retrospective multicenter study, we examined 1322 non-metastatic gastric-cancer patients that underwent curative gastrectomy with D2 versus D1 lymphadenectomy from January 2000 to December 2009. Postoperative complications, overall survival (OS), and disease-specific survival (DSS) according to age and the Charlson Comorbidity Score were analyzed in relation to the extent of lymphadenectomy., Results: Postoperative morbidity was 30.4%. Complications were more frequent in highly co-morbid elderly patients, and, although general morbidity rates after D2 and D1 lymphadenectomy were similar (29.9% and 33.2%, respectively), they increased following D2 in highly co-morbid elderly patients (39.6%). D2-lymphadenectomy significantly improved 5-year OS and DSS (48.0% vs. 37.6% in D1, p < 0.001 and 72.6% vs. 58.1% in D1, p < 0.001, respectively) in all patients. In elderly patients, this benefit was present only in 5-year DSS. D2 nodal dissection induced better 5-year OS and DSS rates in elderly patients with positive nodes (29.7% vs. 21.2% in D1, p = 0.008 and 47.5% vs. 30.6% in D1, p = 0.001, respectively), although it was present only in DSS when highly co-morbid elderly patients were considered., Conclusion: Extended lymphadenectomy confirmed better survival rates in gastric cancer patients. Due to high postoperative complication rate and no significant improvement of the OS, D1 lymphadenectomy should be considered in elderly and/or highly co-morbid gastric cancer patients., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: The optimal treatment of leiomyosarcoma (LMS) of the inferior vena cava (IVC) is still unclear, especially in the metastatic and/or recurrent setting. We herein evaluated the long-term outcome after aggressive management., Methods: Eleven patients underwent surgery for primary LMS of the IVC between 2000 and 2012. The clinical, pathological, and survival data were reviewed., Results: The IVC was managed by graft replacement in four cases, primary repair in four, and ligation in three. The R0 resection rate was 64%. The median follow-up was 60 months. Nine patients developed distant relapse, two of them concomitant local recurrence; no exclusive local recurrence was observed. The 3- and 5-year distant recurrence free survival were 30% and 10%, respectively. The 3- and 5-year overall-survival (OS) were 77.8%. The presence of residual disease after surgery (P = 0.024) and the time to recurrence (P = 0.033) were associated with the OS in a univariate analysis. The time to recurrence was related to the post-metastases survival (P = 0.032)., Conclusions: An adequate surgery minimizes the risk of local recurrence and remains the main treatment for primary LMS of the IVC. Nevertheless, the rate of distant metastases remains extremely high. An aggressive surgical policy may be of benefit to selected patients with metastatic disease. J. Surg. Oncol. 2016;114:44-49. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

In the last 20 years, several clinical trials on neoadjuvant chemotherapy and chemo-radiotherapy as a therapeutic approach for locally advanced gastric cancer have been performed. Even if more data are necessary to define the roles of these approaches, the results of preoperative treatments in the combined treatment of gastric adenocarcinoma are encouraging because this approach has led to a higher rate of curative surgical resection. Owing to the results of most recent randomized phase III studies, neoadjuvant chemotherapy for locally advanced resectable gastric cancer has satisfied the determination of level I evidence. Remaining concerns pertain to the choice of the optimal therapy regimen, strict patient selection by accurate pre-operative staging, standardization of surgical procedures, and valid criteria for response evaluation. New well-designed trials will be necessary to find the best therapeutic approach in pre-operative settings and the best way to combine old-generation chemotherapeutic drugs with new-generation molecules.

Background: According to the TNM classification, the analysis of 16 or more lymph nodes is required for the appropriate staging of gastric cancer. The aim of this study was to evaluate whether this number of resected lymph nodes also affects survival., Methods: This was a multicenter retrospective study based on an analysis of 992 patients with gastric adenocarcinoma who underwent curative resection between January 1980 and December 2009. Patients were classified according to the number of resected lymph nodes (<16 and ≥16 lymph nodes), the anatomical extent of lymph node dissection (D2 vs. D1), and the staging criteria of the seventh edition of the UICC/AJCC TNM staging system. Survival estimates were determined by univariate and multivariate analyses., Results: Based on the univariate and multivariate analyses, the resection of 16 or more lymph nodes was associated with significantly better survival [p = 0.002; hazard ratio (HR) (95% confidence interval [CI]): 0.519 (0.345-0.780)]. Patients with a lymph node count <16 had a significantly worse survival rate than patients with a lymph node count ≥16 in the pN0 (p = 0.001), pN1 (p = 0.007) and pN2 (p = 0.001) stages. In the majority of cases, ≥16 lymph nodes were retrieved when D2 dissection was performed., Conclusions: In gastric cancer the retrieval of less than 16 lymph nodes may cause inaccurate staging and/or inadequate treatment, thus affecting survival rates. These patients should be considered a high-risk group for stage migration and worse survival compared with those who have a retrieval of more than 16 lymph nodes., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Malignancies of the peritoneum remain a challenge in any hospital that accepts to manage them, due not only to difficulties associated with the complexity of the procedures involved but also the costs, which - in Italy and other countries that use a diagnosis-related group (DRG) system - are not adequately reimbursed., Material and Methods: We analyzed data relative to 24 patients operated on between September 2010 and May 2013 with special regard to operating room expenditure, ICU stay, duration of hospitalization, and DRG reimbursement. The total costs per patient included clinical, operating room, procedure, pathology, imaging, ward care, allied healthcare, pharmaceutical, and ICU costs., Results: Postoperative hospital stay, drugs and materials, and operating room occupancy were the main factors affecting the expenditure for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. We had a median hospitalization of 14 days, median ICU stay of 2.4 days, and median operating room occupancy of 585 min. The median expenditure for each case was € 21,744; the median reimbursement by the national health system € 8,375., Conclusions: In a DRG reimbursement system, the economic effort in the management of patients undergoing peritonectomy procedures may not be counterbalanced by adequate reimbursement. Joint efforts between medical and administration parties are mandatory to develop appropriate treatment protocols and keep down the costs., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Introduction: After the introduction of tyrosine kinase inhibitors (TKIs), the role of surgical resection in treating liver metastasis from gastrointestinal stromal tumour (GIST) is unclear. In this study, we evaluated the outcome of patients treated with TKIs followed by surgery for metastatic GIST., Methods: Eleven patients underwent liver resection after downsizing TKIs therapy for metastatic GIST from 2006 until 2010 were reviewed., Results: One and two-year overall survival rates were 80.8 and 70.7%. All patients with an initially resectable tumour were still alive without recurrence. Patients operated on clinical response had a better outcome (1- and 2-year overall survival (OS) rate 100%) than those operated on disease progression (1- and 2-year OS rates 60 and 40%; P = 0.043). No deaths were observed among patients who achieved an R0 resection (R0 versus R1/R2, P = 0.001)., Discussion: R0 resection and clinical response to TKI are predictor of survival. Surgical resection should be performed as soon as feasible in responding patients. In poor responders, surgery may not add any survival benefit, except in localized progressive disease. In resectable metastatic liver disease, preoperative TKIs or upfront surgery followed by adjuvant therapy could be considered. Larger studies are needed to determine the optimum approach in patients with metastatic GIST., (© 2013 The Authors. ANZ Journal of Surgery © 2013 Royal Australasian College of Surgeons.)

Background: After the introduction of tyrosine kinase inhibitors (TKIs), the role of surgical resection in treating liver metastasis from gastrointestinal stromal tumour (GIST) is unclear. In this study, we evaluated the outcome of patients treated with TKIs followed by surgery for metastatic GIST., Methods: Eleven patients who underwent liver resection after downsizing TKIs therapy for metastatic GIST from 2006 until 2010 were reviewed., Results: One and 2-year overall survival (OS) rates were 80.8% and 70.7%. All patients with an initially resectable tumour were still alive without recurrence. Patients operated on clinical response had a better outcome (1-year and 2-year OS rate of 100%) than those operated on disease progression (1-year and 2-year OS rates of 60% and 40%; P = 0.043). No deaths were observed among patients who achieved an R0 resection (R0 versus R1/R2, P = 0.001)., Conclusion: R0 resection and clinical response to TKI are predictors of survival. Surgical resection should be performed as soon as feasible in responder patients. In poor responders, surgery may not add any survival benefit, except in localized progressive disease. In resectable metastatic liver disease, preoperative TKIs or upfront surgery followed by adjuvant therapy could be considered. Larger studies are needed to determine the optimum approach in patients with metastatic GIST., (© 2013 The Authors. ANZ Journal of Surgery © 2013 Royal Australasian College of Surgeons.)

Background: The aim of the present study was to investigate whether microarray gene expression analysis can be used to predict lymph node status in gastric cancer., Methods: Twenty-nine patients undergoing gastrectomy for cancer were enrolled and subdivided according to the pathologic nodal involvement of their disease (N+ vs. N0). Molecular profiling was performed by cDNA microarray on tumor tissue and healthy mucosa. Data were processed to identify differently expressed genes. Selected genes were categorized with gene ontology., Results: Compared to healthy gastric mucosa, 52 genes were differently expressed in N+ patients, and 50 genes in N0 patients. Forty-five genes were similarly regulated in N+ and N0 patients, whereas 12 genes were differently expressed between N+ and N0 patients. Seven genes were exclusively expressed in N+ patients: Egr-1 was upregulated; Claudin-18, AKR1C2, Cathepsin E, CA II, TFF 1, and progastricsin were downregulated. Five genes were exclusively expressed in N0 patients: Complement C5 receptor 1, PLA2/VII, and MMP- 9 were upregulated; MAO-A and ID-4 were downregulated., Conclusions: Microarray analysis could be a valuable tool to identify genes associated with lymph node metastasis in gastric cancer. This technique could improve the selection of patients with locally advanced disease who are candidates for extended lymph node dissection, multimodal treatment options, or alternative therapeutic strategies.

Background: The aims of this study were to evaluate the role of surgery in the management of patients with intraabdominal metastases from melanoma and to investigate the neutrophil to lymphocyte ratio (NLR) as prognostic factor in this group of patients., Methods: Altogether, 44 patients who underwent surgery for Intraabdominal metastases from melanoma with curative, cytoreductive, or palliative intent were analyzed., Results: There were 77 intraabdominal organ resections performed during the 44 operations. R0 resection was achieved in 19 (43 %) cases. Factors associated with R0 resection were an absence of extra-abdominal metastases, low serum lactate dehydrogenase, involvement of fewer than three sites, and the presence of fewer than three metastatic lesions. The 1-, 3-, and 5-year overall survival rates were, respectively, 79, 66, and 44 % in the curative intent group; 36, 18, and 9 % in the cytoreduction group; and 21, 0 and 0 % in the palliation group (curative intent vs. cytoreduction vs. palliation p < 0.001). By Cox's multivariate analysis, the independent prognostic factors were time from excision of primary melanoma to the diagnosis of intraabdominal metastases, NLR, and residual disease after surgery., Conclusions: Our results confirm the usefulness of major surgical interventions as reported in previous studies. We reviewed recent evidence that immunologic phenomena may explain the unexpectedly good response rate in patients with advanced disease. The simple estimation of the NLR has been advocated as a prognostic marker for several cancers. We show that it is likewise useful in metastatic melanoma. We stress the need for developing additional immunologic markers.

Purpose: Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumour of the gastrointestinal tract. The introduction of tyrosine kinase inhibitors (TKIs) has lead to increasing use of combination of medical and surgical therapy. The aim of this study was to look at outcomes from a series of surgically treated GISTs and determine prognostic factors in the context of multimodal therapy., Methods: We analysed 104 single surgeon's patients with GIST. End points of the study were disease-specific survival (DSS), disease-free survival (DFS) and post-operative complications., Results: Three- and 5-year DSS rates were 96.7 and 94.6 %. On univariate analysis, clear resection margins were predictive of DSS. Patients with R2 resection had a worse prognosis (3-year DSS rate of 83.3 %; 5-year DSS rate of 62.5 %) compared to patients with R0 (3-year DSS rate of 98 %; 5-year DSS rate of 98 %) or R1 resection (3-year DSS rate of 100 %; 5-year DSS rate of 100 %) (R0 vs R1 vs. R2 p = 0.001). Pre-operative factors associated with R2 resection were clinical metastatic disease (p < 0.001), non-gastric tumour site (p = 0.002) and large tumour diameter (p = 0.031). Three- and 5-year DFS rates were 65.5 and 59.8 %. Serosal perforation (p = 0.013) and mitotic rate (p = 0.05) were found to be independently predictive of increased DFS. The presence of serosal perforation was associated with tumour site (p = 0.018), mitotic rate (p = 0.035), tumour diameter (p < 0.001), growth pattern (p = 0.007) and age (p = 0.040)., Conclusions: In the multidisciplinary management of GIST, serosal perforation may represent an additional predictor of recurrence along with mitotic rate. Complete macroscopic surgical resection is the most reliable prognostic factor, and an aggressive surgical approach should be advocated.

The introduction of receptor tyrosine kinase inhibitors (TKIs) has revolutionized the management of gastrointestinal stromal tumour (GIST). Strong evidence supports the use of imatinib as first-line treatment in metastatic or unresectable tumours and its efficacy in the post-operative adjuvant setting has been confirmed by phase III trials. There are a number of reports concerning the administration of imatinib in the pre-operative setting, however, the heterogeneity of the terminology used and the indications for pre-operative treatment make it difficult to determine the true value of pre-operative imatinib. Larger studies, or a phase III trial could be helpful but patient accrual and standardization of care could be difficult. We propose a pre-treatment classification of GIST in order to facilitate the comparison and collection of data from different institutions, and overcome the difficulties related to accrual. Moreover, in the current era of multidisciplinary treatment of GIST, an appropriate classification is mandatory to properly design clinical trials and plan stage-adapted treatment., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: The long-term prognosis of patients with stage IV AJCC melanoma is extremely poor. We have previously published short-term clinical outcome and immunological responses to a heat killed Mycobacterium vaccae-based vaccine., Results: In this study we report on a better than expected long-term survival (3-y DSS 29·6%, 5-y, and 7-y DSS both 23·9%) relative to historical controls in the patients who received the vaccine in these trials, published in 1999 and 2003. Although the complete or partial response was only 10%, it was the remarkable response to other interventions upon relapse, such as surgery and radiotherapy followed by stable disease that was previously unexpected., Methods: We reviewed the outcome of 72 patients who were treated with M. vaccae for metastatic melanoma between January 1996 and July 2004., Conclusion: Given this remarkable outcome in stage IV metastatic melanoma and its lack of toxicity we propose that this would make a promising candidate for randomized trials for stage III fully resected melanoma.

Acinar cell carcinoma (ACC) of the pancreas is a rare exocrine tumour for which there is very limited information about chemotherapy regimens and prognosis. Even though there are clinical guidelines for management of ductal cell carcinoma, a definitive and specific regime has not yet been agreed for this type of pancreatic cancer. We report a case of metastatic ACC of pancreas who has been treated with a multimodal approach, including novel combinations of different targeted drugs with conventional chemotherapy, surgery and radiofrequency ablation since the last 11 years. This degree of long term survival has not been reported so far in such a case of metastatic ACC of the pancreas. This case highlights the importance of a personalised multidisciplinary therapeutic strategy, employing locoregional therapies along with combinations of established and novel systemic therapies to control the disease, and the importance of flexibility when instigating new treatment paradigms for progressive cancer. Also, this case demonstrates that complete tumour eradication may not be the sole purpose of surgical oncology., (Copyright © 2013 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Background: The aim of this study was to evaluate the possibility of a different path to achieve curative surgery in patients older than age 70 years and affected by resectable gastric cancer., Study Design: This is a multicentric retrospective study based on an analysis of 1,465 patients with gastric adenocarcinoma who underwent surgery with curative intent. Patients were divided into 2 age groups (younger than 70 years vs older than 70 years) and were evaluated with respect to postoperative morbidity and mortality and survival., Results: Postoperative morbidity and mortality in elderly and nonelderly groups were 24.8% vs 20.6% and 2.6% vs 3.7%, respectively (p = NS). In the elderly group, multivisceral resection was independently associated with surgical complications (hazard ratio [HR] = 1.988; 95% CI, 1.124-3.516; p = 0.018), total gastrectomy with medical complications (HR = 2.007; 95% CI, 1.165-3.459; p = 0.012), and higher postoperative mortality (HR = 4.319; 95% CI, 1.571-11.873; p = 0.005); D1 lymph node dissection was predictive of a lower postoperative mortality rate (HR = 0.219; 95% CI, 0.080-0.603; p = 0.003). Five-year overall survival rates differed significantly in young and elderly patients (58.9% vs 38.9%; p < 0.001), and 5-year cancer-specific survival did not show any significant difference., Conclusions: Age should not be considered as a factor in the selection of treatment for gastric cancer patients. Curative surgery can be performed as safely in elderly patients as in younger patients, with comparable postoperative results and long-term survival rates, although the life expectancy of elderly patients is shorter., (Copyright © 2012 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The log odds of positive lymph nodes (LODDS), defined as the log of the ratio between the numbers of positive and negative lymph nodes, has recently been proposed as a new prognostic index in surgical oncology. The aim of the present study was to investigate whether the LODDS system of lymph node classification was a more accurate prognostic tool than the tumor node metastasis (TNM) and lymph node ratio (LNR) classifications in colon cancer patients., Materials and Methods: Clinicopathologic data from 258 colon cancer patients who had undergone surgical resection were reviewed. Lymph node parameters were categorized according to the Internation Union Against Cancer/American Joint Cancer Commission (UICC/AJCC) TNM staging system, the LNR (LNR0 with ratio ≤ 0.05, LNR1 with 0.05 < ratio ≤ 0.20, LNR2 with ratio > 0.20), and the log odds ratio (LODDS0 ≤ -1.36, -1.36 < LODDS1 ≤ -0.53, and LODDS2 > -0.53)., Results: The LODDS was able to identify patients who would have been included in different prognostic categories, according to both the TNM and LNR. In addition, LODDS was significantly related to the number of positive and negative lymph nodes, as well as the number of examined lymph nodes. In multivariate analysis, LODDS classification (LODDS0: HR 1; LODDS1: HR 3.687, p = 0.003; LODDS2: HR 9.440, p < 0.001) was identified as an independent prognostic factor., Discussion: The LODDS system is a highly reliable staging system with strong predictive ability for patient outcome. Compared with other nodal staging systems, the prognostic power of LODDS is less influenced by the number of lymph nodes dissected and examined.

Background: Perioperative chemotherapy is considered an effective treatment option for patients with gastric carcinoma. We report the results after a 7-year follow-up of a study aimed at evaluating a perioperative chemotherapy protocol in a group of patients with locally advanced gastric cancer (LAGC)., Methods: Between February 1996 and May 2000, 24 patients with LAGC underwent D2-gastrectomy after three preoperative cycles of chemotherapy (Epidoxorubicin, Etoposide, Cisplatinum). Three further cycles were planned after surgery. Differences among groups were evaluated using the chi-square test. Survival rate was calculated after a 7-year follow-up, and differences were assessed using the log-rank test. Multivariate analysis was performed using the Cox proportional hazard model., Results: A total of 24 patients received preoperative chemotherapy and underwent surgical resection. Of these, 17 (71%) received postoperative treatment. The main toxicity was grade 3-4 neutropenia. Curative resection (R0) was achieved in 83.3% of patients. No pathologic complete responses were documented, but tumor downstaging was obtained in 10 of 24 patients (41.7%). Overall median survival was 40 months, and 7-year survival rate was 46%. At univariate and multivariate analysis, R0 resection and tumor diameter were the most important prognostic factors., Conclusion: Long-term results in our series show a survival benefit for LAGC patients treated by perioperative chemotherapy and D2-gastrectomy when compared with previously studied controls who had surgery with postoperative chemotherapy alone. The high rate and prognostic impact of R0 resection in this study stressed the role of the therapy during the preoperative phase.

Objectives: To compare the accuracy of Methylene Blue (MB) targeted biopsies with random biopsies in detecting intestinal metaplasia and dysplasia in the follow-up of patients after gastrectomy for gastric cancer., Methods: Thirty patients (21 Billroth II, 9 Billroth 1) for cancer, referred to the Gastroenterology Unit for an elective esophagogastroduodenoscopy (EGD), were enrolled. All endoscopies were performed with a high-resolution videoendoscope with an adjustable image magnification: EG-485ZH (Fujinon, Omiya, Japan). During EGD three random biopsies were taken in the stomach and, after staining with MB, three targeted biopsies were taken from every stained area., Results: In 28 patients traditional endoscopy showed hyperemia of the anastomosis, in 2 patients a lesion. After MB in 6/30 there were stained area (2 lesions seen with traditional endoscopy and 4 blue areas in other patients). As regards histology: 24 patients showed inflammation, while 2 patients with alterations in traditional endoscopy and with MB showed metaplasia and high grade dysplasia. In 4/30 (13.3%) patients MB guided biopsies showed significant lesions (3 intestinal metaplasia, 1 low grade dysplasia) while random biopsies showed only inflammation., Conclusions: After partial gastrectomy, the mucosa of the residual stomach usually undergoes severe changes, and these lesions are known to be pre-cancerous. The diagnostic accuracy of the MB technique seems to be superior to random biopsies for identification of intestinal metaplasia, dysplasia, and may be helpful in targeting biopsies and early endoscopic treatment.

The mediastinum is located from the thoracic inlet to the diaphragm between the left and right pleural cavities and contains vital structures of the circulatory, respiratory, digestive, and nervous system. Over the years, since there are no fascial or anatomic planes, anatomists and radiologists have suggested various schemes for subdividing the mediastinum and several anatomical and radiological classifications of the mediastinum are reported in the literature. The most popular of these scheme divides medistinum, for purposes of description, into two parts: an upper portion, above the upper level of the pericardium, which is named the superior mediastinum; and a lower portion, below the upper level of the pericardium. For clinical purposes, the mediastinum may be subdivided into three major areas, i.e. anterior, middle, and posterior compartments. The anterior mediastinum is defined as the region posterior to the sternum and anterior to the heart and brachiocephalic vessels. It extends from the thoracic inlet to the diaphragm and contains the thymus gland, fat, and lymph nodes. This article will review surgical anatomy of the anterior mediastinum and will focus on the surgical approch to anterior mediastinum and thymic diseases.

Maximum tumor diameter (DMAX) is considered by many Authors as an im prognostic factor in gastric cancer (GC) correlated with tumor depth (pT). Aim of this retrospective study was to evaluate the prognostic value of DMAX and its predictive role of tumor stage in a series of 164 gastric cancer patients. One hundred and sixty-four patients underwent gastrectomy between January 1994 and December 2004. DMAX value was measured on resected specimens fixed in 10% formalin solution with cut-off of 40 mm. Tumors according to these measurements were classified in DMAX1 < or = mm and DMAX2 >40 mm. The prognostic significance of DMAX along with other factors was evaluated with log-rank test and Cox regression. The correlation between DMAX and other variables was calculated by Spearman test. Overall 5-year survival rate is 56.6%. DMAX resulted significantly linked to survival at univariate analysis (p = 0.0001). The Spearman correlation test showed that DMAX is strongly correlated with tumor stage (positive predictive value of 88.5%), pT, pN, residual of tumor and grading. Our results showed that patients with large tumor at an increased risk for tumor advancement and, therefore, DMAX could represent a useful parameter for selection of patients for neoadjuvant protocols.

Given the overall poor prognosis of patients with esophageal carcinoma and considering the new therapeutic options, surgeons should accurately stage patients preoperatively to appropriately tailor their treatment. CT, MRI, PET and EUS are still inaccurate in evaluating local surgical resectability and in detecting abdominal and thoracic lymph node metastases. Minimally invasive surgical staging is a promising adjunct to esophageal cancer staging. The thoracoscopic and laparoscopic staging provide more accurate information for evaluating local invasion, lymph node and distant metastasis. The greater accuracy afforded by minimally invasive staging is essential for patients who should undergo radical surgical or multimodal treatment. According to data reported by many authors, it seems most useful to combine nonoperative staging procedures as CT/MRI and EUS with minimally invasive staging techniques.